Print Inspection: RL008324

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by: Based on observation and record review, it was determined the facility failed to create an environment in which residents were treated with dignity and respect, were free from neglect, and received services in a manner that protected privacy for 5 of 6 sampled residents (#s 1, 2, 3, 5, and 6) and multiple unsampled residents. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 09/2023 with diagnoses including Alzheimer’s disease and adjustment disorder with mixed anxiety and depressed mood. S/he was subsequently admitted to hospice in 06/2025, with admitting diagnosis of Alzheimer’s disease. During the acuity interview on 12/08/25, Resident 1 was reported as non-verbal, requiring a high degree of care, and receiving treatment for a stage 2 pressure ulcer (open wound). During an interview on 12/11/25 at 10:13 am, Staff 21 (MT) stated the facility RN was available anytime to report abnormal findings, and the MTs used their personal phones for communications with the RN. Staff 21 showed the surveyor her personal phone, which revealed resident’s private medical information. During an interview on 12/11/25 at 11:26 am Staff 18 (MT) confirmed the use of personal phones by facility MTs for communication, including video calls to assess skin impairments. The need to create an environment in which residents received services in a manner that protected privacy and dignity was reviewed with Staff 1 (ED) and Staff 3 (Wellness Director/LPN) on 12/11/25 at 2:07 pm. They acknowledged the findings. 2. Resident 2 moved into the MCC1 in 10/2025 with diagnoses including dementia. On 12/08/25 at 12:12 pm, Resident 2 was observed sitting in a wheelchair asking staff when s/he could take a bath. There was a MT located behind the resident to the left and Staff 14 (CG) was located in front of the resident to the right. Both staff members were within three feet of him/her and Resident 2 was speaking loud enough for staff to hear. When there was no response from either staff member, the resident propelled closer to Staff 14 and repeatedly asked if s/he could have a bath. Neither staff member addressed the resident’s question, looked at him/her while they were asking the question, or said anything to Resident 2. The need to ensure residents were being treated with dignity and respect was discussed with Staff 1 (ED). She acknowledged the findings. 3. The following observations were made in MCC2: a. On 12/08/25, between 2:10 pm and 2:39 pm, observations of an unsampled resident were made in the common area dining room. The resident was pacing around the community, going in and out of the restroom, and pushing on locked doors. When the resident went to go outside to the secured courtyard, a CG stated, “No, no, no! Too much rain,” and did not allow the resident to go outside. When the resident was not allowed to go into the courtyard, s/he turned to the CG, swatted at her, and stated, “Get away from me!” During an interview on 12/08/25, at 2:42 pm, the CG stated she did not know what the facility policy was relating to inclement weather and when it was not safe for residents to go outside. b. Resident 3 moved into the MCC2 in 06/2023 with diagnoses including dementia, adjustment disorder with anxiety, depression, and Alzheimer’s disease. On 12/11/25, at 9:30 am, Resident 3 was observed sitting at a dining room table. S/he got up and walked over to a beverage station to pour him/herself a cup of coffee. The container was empty. The resident took the empty cup to Staff 18 (MT). After the staff member confirmed there was no more coffee left in the container, she told the resident that she was going to get more from the kitchen. Staff 18 took the empty coffee container and the resident’s cup to the kitchen. When the MT returned, she told Resident 3 that the kitchen was brewing a fresh pot of coffee. The resident stated, “They better brew it fast.” At 9:53 am, Resident 3 still did not have a cup of coffee. A staff member brought an unsampled resident a blue cup. The resident had been drinking coffee from a blue cup before Staff 18 took it to the kitchen. This resembled the blue cup from which the resident was previously drinking coffee. When Resident 3 observed staff put the cup down for the unsampled resident, Resident 3 stated, “That’s mine! I already paid for that!” Staff told Resident 3 that the cup was full of oatmeal. The resident asked, “Can I get something to eat?” Staff talked to him/her about some snack choices, and Resident 3 agreed on a half of a sandwich. At 10: 05 am, Staff 18 handed Resident 3 a half of a sandwich on a plate, covered in plastic wrap, then walked out of the unit. The resident had the covered plate on his/her lap and was looking at it and turning the plate around. At 10:27 am, Staff 18 returned to the unit and the resident shoved the plate towards her and stated, “Take it away.” The sandwich was still on the plate and covered in plastic. There were three other staff members on the unit when Staff 18 left. No one offered to help Resident 3 unwrap the sandwich so s/he could eat it. c. On 12/11/25 at 9:40 am, an unsampled resident was observed taking his/her crushed medications in a pureed substance in a plastic cup with a plastic spoon. After s/he was finished swallowing the medications, Staff 18 took the resident to the dining room. The unsampled resident was observed to require meal assistance. The resident’s breakfast was on the table to which s/he was assisted. Staff 18 began to assist the unsampled resident with breakfast using the same plastic spoon the resident used when s/he was administered medications. The unsampled resident was observed to receive meal assistance with silver utensils for prior meals; thus, being assisted with plastic ware did not provide a homelike environment. Staff 18 stopped feeding the resident to do something else, and Staff 17 (CG) continued to assist the resident with eating. He continued using the plastic spoon until the unsampled resident was finished eating. The need to ensure residents were being treated with dignity and respect was discussed with Staff 1 (ED). She acknowledged the findings. 4. Resident 6 was admitted to the facility residential care unit in 11/2023 with diagnoses including heart failure and macular degeneration. The 10/11/25 service plan identified Resident 6 needed cues during meals due to difficulty seeing the meals in front of him/her, needed his/her food to be cut up, and needed nectar thick liquids. S/he preferred “a quieter environment and not excessive noise...” The following observations were made during lunch on 12/08/25 and 12/09/25: * Resident 6 repeatedly asked staff for assistance by saying, “Can you help me?” and/or would wave at a caregiver to come over to the table. Staff would stand over the resident while they provided intermittent assistance of one or two minutes at a time that involved identifying the food, where it was located, and/or cutting the food up into smaller bites. On 12/09/25 the resident attempted to get the attention of staff, saying, “Please help me” with a distressed, panicked look on his/her face. When no staff responded, a surveyor alerted a server to provide assistance; and * A television was playing a crime show during lunch at a loud volume. There were no residents watching the program. Resident 6 sat at the table closest to the television. On 12/09/25 at 11:00 am, Resident 6 was interviewed and indicated the following: * “I wish they would help me eat. They think I can do it, and I can, but it’s hard for me to see my food. I would eat more of my meal if they would just help me.”; * S/he would like to drink coffee “every now and then” but was told s/he had to drink the other pre-thickened beverages; and * The food was described as “average and usually cold” but “I’m hungry so I eat it.” Interviews with multiple staff on 12/08/25 and 12/09/25 indicated the resident wanted assistance with his/her meals but they have been told by management that residents who resided in “assisted living” and needed help eating would need to move downstairs to the memory care unit. In an interview on 12/09/25 at 11:30 am, Staff 7 (MT) indicated the resident could not have coffee because it was not thick enough and was not aware that thickener could be added to coffee to make it nectar thick. On 12/09/25 at 4:15 pm, Staff 1 (ED) indicated she had been recommending the memory care facility for Resident 6 but the family was not agreeable. Staff 1 reported she would communicate to staff to assist Resident 6 with his/her meals. The need to ensure residents were treated with dignity and respect regarding meal service was discussed on 12/10/25 at 2:40 pm with Staff 1. She acknowledged the findings. 5. Resident 5 was admitted to the facility residential care unit in 11/2025 with diagnoses including failure to thrive and cancer. During the acuity interview on 12/08/25, staff indicated the resident was bedbound. The 11/06/25 service plan indicated Resident 5 could feed himself/herself but needed “reminding/cueing to maintain adequate intake due to recent weight loss.” Observations of lunch service on 12/08/25 and 12/09/25 indicated the following: * Resident 5 was in bed sleeping with the head of bed raised about 10 to 20 degrees. A meal tray was on a bedside table out of reach of the resident, with only a plastic fork as an eating utensil; and * On 12/11/25 staff were observed delivering food to the resident which was covered with plastic wrap, placed out of the resident’s reach from his/her bed, and included only a plastic fork for a utensil. Lunch consisted of a thick slice of ham that was not cut up when served to the resident. An interview with Resident 5 on 12/09/25 at 2:30 pm indicated the following: * S/he did not prefer eating with plastic utensils; * “If my food was within reach, I would eat it”; and * The food was “so-so” and cold “most of the time.” Staff interviews on 12/08/25 through 12/11/25 indicated the following: * “I feel bad, sometimes [s/he] doesn’t eat for a few days but we are not supposed to assist [him/her] with eating,”; * “We have been told we are not supposed to [provide meal assistance for Resident 5] but the MT talked with the nurse and got permission to help [him/her] eat.”; * The residents who ate in their room “always” got plastic utensils and it was “usually just a fork or a spoon”; * “We always have to reheat the food because [s/he] likes it warm”; and * The kitchen was often late in getting food served to residents who ate in their rooms. “Breakfast doesn’t arrive sometimes until after 10:00 am and lunch after 1:30 pm. Some residents can’t have their medications until they eat, so that is a problem.” On 12/09/25 at 4:15 pm, Staff 1 (ED) indicated she would ensure Resident 5 would be provided assistance with his/her meals and she would communicate proper meal set-up to staff. The need to ensure residents were treated with dignity and respect regarding meal delivery and assistance was discussed with Staff 1 on 12/11/25 at 2:40 pm. She acknowledged the findings.

- Immediate notification was made to Medication Techs to discontinue using personal phones for communication where resident rights could be compromised. - Notices were posted in each Medication Room as a daily reminder.- Going forward, company cell phones, community iPads, community landlines, and medication tech laptops will be used for private communication. - This system was implemented before survey exit and will be continuously monitored by the Executive Director (ED), Wellness Coordinator, Wellness Director, and RN consulting company to ensure private communication occurs only on company devices. - A Caregiver/Medication Tech meeting will be held on 01/13/2026 to provide a refresher co urse on Resident Rights, emphasizing dignity, proper approach to residents with dementia, resident choice, and individualized needs. - Daily floor check-ins by the ED, Wellness Coordinator, and Wellness Director will ensure dignity and proper communication. - A Temporary Service Plan was implemented before survey exit to ensure residents needing feeding assistance are offered help at each meal and food is within reach if they choose to feed themselves. Care plans will reflect this as an ADL when needed. Weekly check-ins wi ll confirm assistance is provided as needed. -This will be monitored by the Executive Director, Wellness Coordinator, and Wellness Director.

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by:

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an injury of unknown cause was reported to the local Seniors and People with Disabilities (SPD) office as suspected abuse when the facility’s investigation could not reasonably conclude that the physical injury was not the result of abuse for 1 of 1 sampled resident (# 2), who sustained an injury of unknown cause. Findings include, but are not limited to: Resident 2 moved into the MCC1 in 10/2025 with diagnoses including dementia. A review of the resident's clinical record, including progress notes and incident reports, identified the following: On 11/07/25, an incident form was created and noted, “a bruise [on the resident’s right] breast nipple.” The incident form included the question, “Is abuse suspected?” In response, staff wrote, “We don’t know at this time.” During the facility’s investigation, Resident 2 was asked what happened. The resident stated that s/he did not know. On 11/08/25, Staff 3 (Wellness Director /LPN) documented in a progress note that “care staff reported that resident has a bruise on [his/her] right breast.” Staff 3 documented the bruise was “below [his/her] right nipple” and was “approximately 1.5 [centimeters by] 1.5 [centimeters]” and was a “light purplish color.” On 12/09/25 at 10:24 am, Staff 3 was unable to locate documented evidence that the injury of unknown cause had been reported to the local SPD office. At the request of survey, the facility reported the incident on 12/09/25 at 12:38 pm and provided the documentation to survey at 1:07 pm. The need to ensure injuries of unknown cause were reported to the local SPD office as suspected abuse when the facility’s investigation could not reasonably conclude that the physical injury was not the result of abuse was discussed with Staff 1 (ED) and Staff 3 on 12/09/25 at 10:24 am. They acknowledged the findings.

- Incident reports will be reviewed promptly within 24 hours to ensure cases where abuse cannot be ruled out are reported timely. - Morning manager meetings will include discussions to confirm no reports are missed. - Daily checks of Incident Reports in Yardi by the ED, Wellness Coordinator, and Wellness Director will ensure compliance

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by:

Any/All reports that can not be rule out abuse and neglect will be investiaged and turned into APS within 24 hours. The system will be corrected by oversight of the ED, Wellness Director, and Wellness coordinator to disucss in morning clinical meetings if reports have been made that need to be reported each day. This will be evaluated daily or as reports are made to the facility. The ED, Wellness Director, and Wellness Coordinator will be responsible for contiuned monitoring.

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by:

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the initial evaluation addressed all required elements for 2 of 2 sampled residents (#s 2 and 5) and the initial evaluation was updated and modified as needed during the first 30 days following the resident’s move-in to the facility for 1 of 1 sampled resident (# 2) who had resided at the facility for over 30 days. Findings include, but are not limited to: 1. Resident 2 moved into the MCC1 in 10/2025 with diagnoses including dementia. a. The resident’s initial evaluation was reviewed and was lacking the following required elements: * Customary routines, including eating and bathing; * Interests, hobbies, social, leisure activities; * Ability to understand and be understood; * Non-pharmaceutical interventions for pain; and * Recent Losses. b. There was no documented evidence the initial evaluation had been updated and modified as needed during the first 30 days following Resident 2’s moving into the facility. The need to ensure the initial evaluation addressed all required elements and the initial evaluation was updated and modified as needed during the first 30 days following the resident’s admission was discussed with Staff 1 (ED) and Staff 3 (Wellness Director/LPN) on 12/11/25 at 12:35 pm. No additional documentation was received. 2. Resident 5 moved into the facility residential care unit in 11/2025 with diagnoses including failure to thrive and cancer. The resident's initial evaluation was reviewed, and it failed to address the following required elements: * Interests, hobbies, social, leisure activities; * Pain, including non-pharmaceutical interventions; and * Recent losses. The need to ensure the initial evaluation included all required elements was discussed with Staff 1 (ED) and Staff 3 (Wellness Director/LPN) on 12/11/25. They acknowledged the findings.

- Initial evaluations will be reviewed by the ED, Wellness Coordinator, and Wellness Direc tor before admission to ensure completeness. - 30-day evaluations will be completed and double-checked. - Upcoming evaluations will be reviewed in daily morning meetings to ensure timely completion. -This will be monitored by the ED, Wellness Coordinator, and Wellness Director.

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991 This Rule is not met as evidenced by:

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs, provided clear directions to staff regarding the delivery of services and/or were completed quarterly for 5 of 6 sampled residents (#s 1, 2, 3, 5, and 6) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the MCC1 in 10/2025 with diagnoses including dementia. The resident's clinical record was reviewed, staff and the resident’s family were interviewed, and observations were made. The service plan did not provide clear direction to staff in the following areas: * The use of a walker; * The use of a gait belt; * Ability to use the call light; * Assistance needed for all grooming and personal hygiene needs; * Level of assistance needed for toileting; * Ability to consistently verbalize the need to use the restroom; * The use of protective undergarments; * Behavior interventions when s/he verbalized concerns about money; and * Emergency evacuation assistance needed. The need to ensure service plans were accurate and provided clear direction regarding the delivery of services was discussed with Staff 1 (ED) and Staff 3 (Wellness Director /LPN) on 12/11/25 at 12:35 pm. They acknowledged the findings. 2. Resident 3 moved into the MCC2 in 06/2023 with diagnoses including dementia, adjustment disorder with anxiety, depression, and Alzheimer’s disease. a. The resident's clinical record was reviewed, interviews were completed with staff, and observations were made. The service plan did not provide clear direction to staff in the following areas: * Exit seeking behavior; * Reminders to not put dirty clothes back in the closet; * Independently cleaned his/her body at the sink each day; * Person-centered interventions for behaviors; and * Preference of not being touched. b. The service plan that staff had access to was dated 08/13/25, thus had not been updated quarterly. The need to ensure service plans were accurate and provided clear direction regarding the delivery of services and were updated quarterly was discussed with Staff 1 (ED) and Staff 3 (Wellness Director/LPN) on 12/11/25 at 12:35 pm. They acknowledged the findings. 3. Resident 5 was admitted to the facility residential care unit in 11/2025 with diagnoses including failure to thrive and cancer. The resident’s record was reviewed, including the current service plan, dated 11/06/25, observations were made, and interviews with staff were conducted. The following was identified: The service plan was not reflective of the resident’s current care needs and/or lacked clear instruction in the following areas: * Meal delivery, including cutting up meat and vegetables, meal tray placement, and positioning when eating in bed; * Dining assistance, including as-needed cueing and assistance; * Food and fluid preferences; * Pain, including location, how the resident expressed pain, and pharmaceutical and non-pharmaceutical interventions; * Preferences for leaving the door open; * Skin treatments including applying barrier cream following brief changes; * How often to perform safety checks and repositioning when in bed; and * Outside providers who were providing services. The need to ensure service plans were reflective of the residents’ current care needs and included clear instructions to staff was reviewed with Staff 1 (ED) and Staff 3 (Wellness Director/LPN) on 12/11/25 at 2:40 pm. They acknowledged the findings. 4. Resident 6 was admitted to the facility residential care unit in 11/2023 with diagnoses including heart failure and macular degeneration. The resident’s record was reviewed, including the current service plan, dated 10/11/25, observations were made, and interviews with staff were conducted. The service plan was not reflective of the resident’s current care needs and/or lacked clear instruction in the following areas: * Dining assistance; * Aspiration precautions when drinking fluids in bed; * Use of side rails, including safety checks and when to position up and down; and * Use of pillow under leg when in bed. The need to ensure service plans were reflective of the residents’ current care needs and included clear instructions to staff was reviewed with Staff 1 (ED) and Staff 3 (Wellness Director/LPN) on 12/11/25 at 2:40 pm. They acknowledged the findings. 5. Resident 1 was admitted to the facility in 09/2023 with diagnoses including Alzheimer’s disease and adjustment disorder with mixed anxiety and depressed mood. S/he was subsequently admitted to hospice in 06/2025 with admitting diagnosis of Alzheimer’s disease. Observations were made of the resident's care on 12/09/25. Interviews with the resident’s family member, facility staff, and the resident’s outside provider were conducted. The service plan, updated on 10/01/25, was reviewed. Resident 1's service plan lacked clear instructions to staff in the following areas: * Specific changes of condition to report to hospice; * Instructions to staff when resident refused care; * How the resident expressed hallucinations and delusions; and * Aspiration precautions and interventions while choking. The need to ensure service plans provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (ED) and Staff 3 (Wellness Director/LPN) on 12/11/25 at 2:07 pm. They acknowledged the findings.

-Service plans will be updated with accurate details in all areas not met and revised as changes occur, including needs, interventions, ADLs, and resident preferences. - Detail checks will occur during initial, 30-day, and quarterly evaluations. - The ED, Wellness Coordinator, and Wellness Director will monitor due dates in Yardi to ensure timely completion.

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by:

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure resident-specific actions or interventions were determined, documented, and communicated to staff on all shifts for short-term changes of condition, for 1 of 1 sampled resident (# 11) who experienced a change of condition. Findings include, but are not limited to: Resident 11 was admitted to the Memory Care Community Two (MCC2) unit in 12/2025 with Alzheimer’s dementia. Resident 11’s progress notes indicated the following: * On 02/21/26 Resident 11 was placed on alert and staff noted, “During this shift [Resident 11] expressed suicidal comments to the care staff and was observed cleaning the butterknives while making comments about ending [his/her] life … went thru [sic] residents [sic] room to look for any sharp objects and took them out. Nurse was notified on this.” * Staff documented in progress notes from 02/22/26 through 02/24/26 that the resident was at baseline with his/her behaviors and no statements of suicidal ideations had been voiced. Observations were made on the MCC2 unit on 02/25/26. At 4:31 pm Resident 11 entered the dining room, approached an unsampled resident who was seated at the table, and asked if the resident had a knife so s/he could cut “right here in my throat” and motioned with his/her finger across his/her neck. Resident 11 leaned down again, muttered something unintelligible to the resident, stood up and made the same motion to his/her neck and stated, “I’d just like to go to heaven.” Resident 11 then pointed at the surveyor’s pen and sat down next to the surveyor. Resident 11’s hands were shaky, s/he displayed a worried look on his/her face, and s/he asked the surveyor if s/he had a knife “or the pen will do.” S/he repeated in that conversation, “I just want to go to heaven.” On 02/25/26 at 4:36 pm, the surveyor alerted Staff 5 (MT/CG) of the observation and interview with Resident 11. Staff 5 stated the facility was aware of his/her suicidal ideations from 02/21/26, a temporary service plan (TSP) was in place, and staff were monitoring the resident. On 02/25/26 at 5:03 pm, the surveyor shared the observations and interviews with Staff 3 (Director of Wellness/LPN) and he indicated he had not been aware of Resident 11’s suicidal ideation statements made on 02/21/26. A copy of the TSP related to suicidal ideations was requested. On 02/25/26 at 5:11 pm. Staff 3 and Staff 5 could not provide a TSP and acknowledged there was no documented evidence the facility had determined actions or interventions and communicated to staff to address Resident 11’s suicidal ideation on 02/21/26. Staff 3 immediately created a TSP that instructed staff to provide “frequent safety checks … avoid sharp objects like knife, pen, pencils.” Staff were also instructed to contact the physician or call 911 if s/he demonstrated any suicidal behavior. On 02/25/26 at 5:22 pm, the new TSP was provided. The surveyor then observed staff place a fork, spoon, and butterknife next to Resident 11 with dinner. The surveyor alerted Staff 3 and Staff 5 of this observation, and the fork and butterknife were immediately removed. Staff 3 stated he would ensure all staff on all shifts were made aware of the interventions identified in the TSP. An additional TSP was provided on 02/26/26, at 1:15 pm, that included how staff should respond to verbal comments of suicidal ideation, that they should check on the resident every hour, and what behaviors would warrant a call to 911. Staff working on the MCC2 unit were also trained in suicidal behaviors, and staff removed from the environment any devices that could possibly aid in a suicide attempt. The need to ensure the facility determined and documented resident-specific actions or interventions needed to address a resident’s condition and communicated the determined actions and interventions to staff was discussed with Staff 3 (Director of Wellness/LPN) on 02/25/26 at 5:03 pm and on 02/27/26 at 11:50 pm. He acknowledged the findings.

Short term change in conditions or residents put on alert for any reasons will have an immiediate tempary service plan put in place. This will be corrected by initiating the tempary service plan for all short term changes and residents on alert to include relevant information for each situation such as interventions, symptoms to look out for, instructions for new/changed care. This will be evaluated each day in wellness clinical meeting and each day as new changes of conditions and alerts happen. Temporay service plans will be initiated by Medication techs, Wellness Coordinator, Wellness Director, and ED. This will be monitored by the ED, Wellness Director, and Wellness Coordinator.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by:

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility MCC1 in 09/2023 with diagnoses including Alzheimer’s disease and adjustment disorder with mixed anxiety and depressed mood. S/he was subsequently admitted to hospice in 06/2025 with admitting diagnosis of Alzheimer’s disease. During the acuity interview on 12/08/25, Resident 1 was reported to be non-verbal and require a high degree of care, including a pureed texture diet and assistance with meals. During the survey, from 12/08/25 through 12/11/25, the surveyor obtained permission from the facility and observed facility staff provide personal care and feeding to Resident 1. The resident required full assistance from staff. On multiple instances, staff donned gloves without first performing hand hygiene, did not change single-use gloves between clean and dirty tasks, and performed meal assistance without wearing aprons. On 12/08/25 at 12:44 pm, Staff 11 (CG) was observed to transfer Resident 1 from his/her wheelchair to the bed using a mechanical lift, placing a trash can on the resident’s bed, providing personal care, and administering cream treatment to the resident without changing soiled gloves. On 12/09/25 at 11:44 am, Staff 14 (CG) was observed placing a gloved finger in resident’s two food bowls and wiping the fingers with a napkin. When asked of the purpose, Staff 14 stated, “to check temperature.” The need to establish and maintain effective infection prevention and control protocols was reviewed with Staff 1 (ED) and Staff 3 (Wellness Director/LPN) on 12/11/25 at 2:07 pm. They acknowledged the findings. 2. Resident 6 was admitted to the facility residential care unit in 11/2023 with diagnoses including heart failure and macular degeneration. During the acuity interview on 12/08/25, the resident was identified to need cueing for meal assistance because of his/her poor vision. Multiple observations during meal service on 12/08/25 identified Resident 6 waving his/her hand to motion a staff member to come to the table and provide meal assistance. Between 1:02 pm and 1:16 pm, the resident asked and/or motioned for staff to come over to his/her table three times. Staff were observed to pick up his/her utensil and use it to either cut up the food, point at where the food was located, or scoop up a bite of food. Staff handed the utensil back to the resident to resume eating. Staff were not observed to perform hand hygiene prior to assisting Resident 6 or prior to resuming meal service. The need to ensure infection prevention and control protocols were maintained was discussed with Staff 1 (ED) and Staff 3 (Wellness Director/LPN) on 12/11/25 at 2:40 pm. They acknowledged the findings. 3 .During the survey, between 12/08/25 and 12/11/25, multiple meal observations were made of direct care staff providing meal service to residents in the two MCC units. On 12/08/25 at 11:55 am in MCC1, Staff 14 (CG) was observed sitting beside a resident who required assistance with his/her meal. Staff 14 had donned gloves prior to the observation. At 12:03 pm, kitchen staff brought three bowls covered in plastic wrap. Staff 14 took the wrap off and began to assist the resident with his/her meal. She stopped the assistance and got up to push the resident’s wheelchair closer to the table, touching the wheelchair grips. She sat back down at the table and continued to assist the resident with his/her lunch without changing the soiled gloves or performing hand hygiene prior to resuming meal assistance. Staff 14 was not wearing an apron or another protective barrier while assisting the resident to eat during his/her lunch. On 12/09/25 at 11:59 am in MCC2, Staff 23 (MT) was observed sitting beside an unsampled resident who required assistance with his/her meal. Staff 23 was wearing gloves but was not wearing an apron or any other protective barrier, nor was her hair restrained. Staff 23 was observed opening and shutting a cabinet door, delivering a plate of food and a beverage to a different resident, and handing another staff members keys attached to a lanyard without changing soiled gloves or performing hand hygiene. There were two CGs observed assisting residents in the dining room and delivering plates and beverages to residents who chose to eat their lunch in their units. Neither one of them were wearing an apron or any other protective barrier over their clothing. On 12/11/25 at 9:43 am in MCC2, Staff 18 (MT) was observed sitting beside an unsampled resident who required assistance with his/her meal. Staff 18 was wearing gloves but was not wearing an apron or any other protective barrier over her clothes, nor was her hair restrained. While the resident was eating, Staff 18 needed to take a lunch break, so Staff 17 (CG) began assisting the resident with breakfast. Staff 17 was wearing gloves but was not wearing an apron or any other protective barrier over his clothes. Staff 17 touched the television remote and used his walkie talkie while assisting the unsampled resident with his/her meal. Staff 17 did not perform hand hygiene or change his gloves between the tasks. The need to ensure infection prevention and control protocols were maintained was discussed with Staff 1 (ED) during the survey. She acknowledged the findings.

- Re-training on infection control will include proper glove use, sanitary habits, and mea l assistance. - Aprons will be provided to each department for easy use during meal periods. - In-person training will occur for Caregivers and Medication Techs, followed by all staff . - Daily checks will ensure compliance, especially during meal times. - All management will oversee staff compliance, with ED and infection control specialists responsible for enforcement.-

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by:

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure treatment orders were carried out as prescribed for 2 of 6 sampled residents (#s 3 and 6) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 6 was admitted to the facility residential care unit in 11/2023 with diagnoses including heart failure and macular degeneration. Review of Resident 6's current physician orders, dated 10/08/25, MARs, dated 11/01/25 through 12/08/25, and weight records, dated 06/2025 through 12/2025, revealed the following: Physician’s orders included “weigh [Resident 6] every 2 weeks” and report to the physician “any weight loss or gain of 3 [pounds].” According to the resident’s weight records, the following was identified: * 07/10/25: 142.6 pounds; * 07/29/25: 147.1 pounds; * 10/10/25: 142.26 pounds; and * 10/29/25: 147.1 pounds. On 12/11/25 at 2:40 pm, in an interview with Staff 3 (Wellness Director/LPN), she acknowledged there was no documented evidence the physician was notified of the 4.5 pound and 4.84 pound weight gains on 07/29/25 and 10/29/25, respectively. Additionally, weight records indicated the resident was weighed one time in 06/2025 and 09/2025, not every two weeks as the physician ordered. The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 1 (ED) and Staff 3 on 12/11/25 at 2:40 pm. They acknowledged the findings. No further documentation was provided. 2. Resident 3 moved into the MCC2 in 06/2023 with diagnoses including dementia, adjustment disorder with anxiety, depression, and Alzheimer’s disease. The resident’s physician’s orders, MARs, dated 11/01/25 through 12/08/25, and weight records, dated 05/2025 through 12/2025, reflected the following: a. Physician’s orders directed staff to weigh Resident 3 each month on the 21st during the morning. There was no documented evidence the resident was weighed in 06/2025, 08/2025, or 11/2025. b. Resident 3 received amlodipine and lisinopril each day at 8:00 am to help treat high blood pressure. Physician’s orders directed staff to take the resident’s blood pressure every day at 8:00 am and to hold the medications if his/her systolic blood pressure was “less than 110.” There was no documented evidence staff took Resident 3’s blood pressure 14 of the 37 days reviewed. Both medications were administered on those 14 days. In an interview at 1:17 on 12/09/25 with Staff 23 (MT), she demonstrated that the daily blood pressure was a separate task entry from administering blood pressure medications. Once the MT had entered the blood pressure, she couldn’t go back into the entry to see what the numbers were when she was administering medication. In an interview at 12:35 pm on 12/11/25 with Staff 3 (Wellness Director/LPN), he indicated that he reviewed MARs monthly but didn’t look at every single MAR. The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 1 (ED) and Staff 3 on 12/11/25 at 12:35 pm. They acknowledged the findings and no additional information was received.

-Weight and blood pressure orders will be reviewed by Wellness Director and than residnet put on alert to be closer monitored. -Refusals by resident will be documented, physican notified and approiate documenation and follow up will be done to ensure orders are being followed. Wellness director will ensure Med Techs know how to record properly in Yardi so that it can be properly tracked as well. -This will be evaluated per the order. Weights will be evaluated weekly to ensure none fall behind. For daily orders such as Resident 3's blood pressure, resident will be put on alert to ensure it is taken before medication is admistered. -The corrections will be done and monitored by the Wellness director and followed up on by the Wellness coordinator.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by:

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to notify the physician when a resident refused to consent to orders for 1 of 1 sampled resident (# 3) who had documented treatment refusals. Findings include, but are not limited to: Resident 3 moved into the MCC2 in 06/2023 with diagnoses including dementia, adjustment disorder with anxiety, depression, and Alzheimer’s disease. The resident’s 11/01/25 through 12/08/25 MARs, physician orders, and 09/04/25 through 12/05/25 progress notes were reviewed. The resident refused having his/her blood pressure taken on 10 occasions between 11/01/25 and 12/08/25. There was documented evidence the resident had refused medications on multiple days, as well; however, on 12/09/25 at 1:17 pm, Staff 23 (MT) confirmed that she faxed Resident 3’s medication refusals to the physician each time the resident refused them. Staff 23 stated she gave the verification of the faxes to Staff 3 (Wellness Director /LPN) for review. Staff 23 stated she did not notify the physician when the resident refused treatments. The need to notify the physician of resident treatment refusals was discussed with Staff 1 (ED) and Staff 3 on 12/11/25 at 12:35 pm. They acknowledged the findings.

-Internal service plan will be put in place for all refusals of medications, treatments, or any physcians order not completed to notify physican day of refusal and Wellness Director. -Re-training and notices in Med Rooms will be put in place as well to ensure this is standard practice. -The Wellness Director and Wellness Coordinator will evaluate, and monitor daily.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber. This Rule is not met as evidenced by:

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents' MARs included resident-specific parameters and instructions for PRN medications, included reasons for use, and were initialed by the person administering the medication for 2 of 6 sampled residents (#s 1 and 3) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 1's MAR, dated 11/01/25 through 12/08/25, and physician orders were reviewed and revealed the following PRN medications lacked instructions for sequential order of use: * Acetaminophen 325mg (for pain); * Acetaminophen rectal suppository (for pain); * Morphine 20mg/5ml (for pain); * Bisacodyl rectal suppository (for constipation); * Senna 8.6mg (for constipation); * Ondansetron 4mg (for nausea); and * Scopolamine transdermal patch (for nausea). The need to ensure MARs were accurate and provided instructions for PRN medications was reviewed with Staff 1 (ED) and Staff 3 (Wellness Director/LPN) on 12/11/25 at 2:07 pm. They acknowledged the findings. 2. Resident 3 moved into the MCC2 in 06/2023 with diagnoses including dementia, adjustment disorder with anxiety, depression, and Alzheimer’s disease. The resident’s MARs, dated 11/01/25 through 12/08/25, and physician’s orders were reviewed. The following inaccuracies were noted: a. Scheduled quetiapine was missing a reason for use. b. Initials of the person administering the medication or treatment were missing for the following: * Donepezil (for dementia) - 11/21/25; * Multiple vitamins with minerals (for eye health) - 11/21/25; * Sodium fluoride (for oral care) - 11/21/25; and * Bowel tracking - 11/02/25 and 11/21/25. The need to ensure MARs included reasons for use and were initialed by the person who administered medications and treatments were accurate was reviewed with Staff 1 (ED) and Staff 3 (Wellness Director /LPN) on 12/11/25 at 12:35 pm. They acknowledged the findings.

1. Immediate Corrections: o All resident MARs have been reviewed and updated to ensure: ? PRN medications include resident-specific parameters and sequential instructions ? All medications and treatments have documented reasons for use ? Staff initials are documented in the EMR immediately after each medication or treatment is administered o Charts were corrected as needed to reflect accurate and complete instructions and documentation. 2. System Changes / Responsible Party Updates: o Community LPN charts all PRN parameters for residents. o ANDS RN reviews PRN parameters after completion by the LPN on a consistent basis to ensure accuracy and resident-specific instructions. o Community ED will review PRN documentation and MARs for compliance with facility policies. o On-site LPN/Wellness Director oversees medication administration by med techs and ensures MARs are accurately documented with initials and reasons for use. o All UAPs attended a Safety Medication Class on 12/22 and 12/30 to reinforce proper medication administration and documentation practices. 3. Monitoring: o Ongoing review of PRN parameters, reasons for use, and staff documentation is conducted to ensure continued compliance. o Any missing documentation or errors are corrected immediately. o Findings and corrections are documented and available for review to demonstrate compliance. Responsible Parties: Community LPN, ANDS RN, Community ED, and on-site LPN/Wellness Director

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by:

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications for 2 of 3 sampled residents (#s 1 and 2) who were prescribed PRN psychotropic medications. Findings include, but are not limited to: 1. Resident 1 was admitted to the MCC1 in 09/2023 with diagnoses including Alzheimer’s disease and adjustment disorder with mixed anxiety and depressed mood. S/he was subsequently admitted to hospice in 06/2025 with admitting diagnosis of Alzheimer’s disease. Review of Resident 1's clinical record indicated the following: * Resident 1 was prescribed lorazepam 0.5 mg as needed for agitation, anxiety, or restlessness; and * The MAR from 11/01/25 through 12/08/25 indicated staff administered two doses of PRN lorazepam. There was no documented evidence the staff attempted and documented non-pharmacological interventions with ineffective results prior to administering the medication. During an interview on 12/09/25 at 3:07 pm, Staff 22 (MT) confirmed non-pharmacological interventions were not attempted, and on 12/11/25 at 10:13 am, Staff 21 (MT) stated non-pharmacological interventions had been given in the past but were not documented. The need to ensure non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications was reviewed with Staff 1 (ED) and Staff 3 (Wellness Director/LPN) on 12/11/25 at 2:07 pm. They acknowledged the findings. 2. Resident 2 moved into the MCC1 in 10/2025 with diagnoses including dementia. A review of the resident’s clinical record indicated the following: * Resident 2 was prescribed risperidone, 0.5 mg, as needed for agitation; and * MARs, dated 11/01/25 through 12/08/25, indicated staff administered 22 doses of PRN risperidone. There was no documented evidence the staff attempted and documented non-pharmacological interventions with ineffective results prior to administering the medication. On 12/11/25 at 12:07 pm, Staff 21 (MT) confirmed no non-pharmacological interventions had been documented as tried with ineffective results prior to the administration of the PRN psychotropic. The need to ensure non-pharmacological interventions had been tried with ineffective results prior to the administration of a PRN psychotropic medication was reviewed with Staff 1 (ED) and Staff 3 (Wellness Director/LPN) on 12/11/25 at 12:35 pm. They acknowledged the findings.

-Internal Service Plans will be put in place to provide and document non-pharmacutical interventions for PRN psychotropic Medications. - Resident specifc interventions will be properly care planned as well to help staff have options to try before giving medication.Behvioral training will be given as well. -Staff are to notify Wellness Director, ED, or Wellness coordinator when interventions have failed and medication needs admistered to ensure all non-pharmacutical efforts have been made and properly documented first. -This will be monitored as needed per resident need, and during morning wellness meetings. The Wellness Director, and Wellness Coordinator will be responsible to monitor and ensure follow through.

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility. This Rule is not met as evidenced by:

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure a supportive device with restraining qualities was assessed by an RN, PT, or OT prior to use, caregivers were instructed on the correct use of and precautions for the device, and use of the device was included in the resident’s service plan for 2 of 2 sampled residents (#1 and 6) who had side rails on their bed. Findings include, but are not limited to: 1. Resident 6 was admitted to the facility residential care unit in 11/2023 with diagnoses including heart failure and macular degeneration. Observations of the resident and the resident's room on 12/08/25 at 1:36 pm identified Resident 6 had side rails in the up position on each side of the bed. A current assessment for the side rail was requested on 12/09/25 and a copy of the initial assessment, completed on 10/28/25, was provided. Review of the side rail assessment identified the following: * The assessment had been completed by Staff 3 (Wellness Director/LPN) and lacked documented evidence it had been completed by an RN, PT or OT for the use of side rails; and * There was no documented evidence caregivers were instructed on the correct use of and precautions for the device. Additionally, review of the resident’s most recent service plan and temporary service plans lacked documented evidence of side rail instructions. The need to ensure an assessment was completed by an RN, PT, or OT and documentation requirements for side rail use was discussed with Staff 1 (ED) and Staff 3 on 12/11/25 at 2:40 pm. They acknowledged the findings. No additional documentation was provided. 2. Resident 1 was admitted to the MCC1 in 09/2023 with diagnoses including Alzheimer’s disease and adjustment disorder with mixed anxiety and depressed mood. S/he was subsequently admitted to hospice in 06/2025 with admitting diagnosis of Alzheimer’s disease. During the acuity interview on 12/08/25, Resident 1 was identified as having a side rail on his/her bed. Upon observation on 12/08/25, Resident 1's hospital bed was noted to have two half-length side rails in the up position. There was no documented evidence the facility registered nurse, a physical therapist, or an occupational therapist conducted a thorough assessment or other less restrictive alternatives were evaluated prior to the use of the device. During a phone interview on 12/11/25, Witness 1 (Family Member) confirmed the family was aware of the side rail use and had agreed to it as a measure for assistance with bedside mobility. The need to ensure the facility registered nurse, a physical therapist, or an occupational therapist had conducted a thorough assessment, and other less restrictive alternatives were evaluated, prior to the use of a supportive device with restraining qualities was reviewed with Staff 1 (ED) and Staff 3 (Wellness Director/LPN) on 12/11/25 at 2:07 pm. They acknowledged the findings.

plan is in place for RN delgation company ANDS to preform assesment of any supportive devices with restraining qualites, and to give clear instructions for staff. - Wellness Coordinator and/or Wellness Director will update care plan to reflect chagnes. Internal service plan will be intiated to give staff clear instructions on correct use and precautions. -This area will be evaluated as changes occur, during weekly RN consulting meeting, and morning clinical meeting. -This will be monitored by Wellness Corrdinator, Wellness Director, ED, and RN Consulting company ANDS.

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by:

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) was updated and reviewed for each resident before they moved into the facility, whenever there was a significant change of condition, and updated no less than quarterly at the same time the resident’s service plan was updated for 3 of 6 sampled residents (#s 2, 4 and 6). Findings include, but are not limited to: During the acuity interview, at 9:43 am on 12/08/25, Staff 3 (Wellness Director/LPN), Staff 21 (MT), and Staff 11 (CG) confirmed the facility census was at 66 residents. The facility’s ABST data was reviewed on 12/08/25 and revealed the following: * There was no documented evidence Resident 2’s ABST data had been updated before the resident moved in; * There was no documented evidence Resident 4’s ABST data had been updated following a significant change of condition; and * There was no documented evidence Resident 6’s ABST data had been updated quarterly. The need to ensure residents’ ABST data was updated following a significant change of condition, no less than quarterly, and prior to move-in was reviewed with Staff 1 (ED) and Staff 3 (Wellness Director/LPN) on 12/11/25 at 2:07 pm. They acknowledged the findings.

ABST will be updated berfore move in, any time signifgant changes occur, and quarterly. New residents will be added as soon as care plan is created, berfore move in. -Resident chages and quartley evaultions will be discussed in daily clinical meetings and will be updated as they occur. -This will be evaluated daily as need arrises. -The ED will be responsible for updates with assistance from Wellness Coordinator.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by:

The ABST will be reviewed weekly and as new move ins, care plan updates, and changes of conditon occur. This will be corrected by training the Wellness Coordinator and Wellness Director as well on updating. And weekly reviews to ensure all updates have been made. This will be evaluated weekly or as new move ins, care plans update, and changes in condition occur. The ED will be responsible for the contiued monitoring

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by:

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted every other month and recorded according to Oregon Fire Code (OFC) and fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to: On 12/09/25 at 3:10 pm, six months of facility fire drill and fire and life safety records, from 06/2025 through 11/2025, were requested and reviewed with Staff 4 (Maintenance Director). The following was determined: a. The facility lacked documented evidence unannounced fire drills were conducted and recorded at least every other month. b. Fire drill records lacked documentation of the following required elements: * Location of the simulated fire origin; * Escape route used; * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; * Evacuation time period needed; * Staff members on duty and participating; and * Number of occupants evacuated. c. The facility lacked documented evidence fire and life safety instruction was provided to staff on alternate months from fire drills. The need to ensure fire drills were conducted per the OFC and staff were provided fire and life safety instruction on alternate months was discussed with Staff 1 (ED) on 12/11/25 at 4:05 pm. She acknowledged the findings.

Maintance Director has scheduled fire drills for the year. They will be documented for the required elements; Location, escape route, promlems that occurred, evacuation time/ reponse time, staff who participated, and residents. -The schedule will be set in the ED and Maintance directors calendars.This will be evaluated every other month. -The ED and Maintance director will be responsible to ensure these are completed.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by:

Fire Drills will be scheduled in advance by Maintance Director. Residents will be included by evacuating and re-located. Escape routes will be documented and problems that occurred, and number of residents/staff who participated will be documented as well. Drills will be scheduled and put on all management calanders. Documentation will be created to have a format that has all areas of concern to be filled out. This will need to be evaluated after each drill. The Maintance Director will be responsible for corrections and monitoring with ED to confirm completion each time.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by:

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents were instructed on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building within 24 hours of admission and failed to re-instruct residents on fire and life safety at least annually, with a written record of the content of the training sessions and the residents attending, per the Oregon Fire Code (OFC). Findings include, but are not limited to: Facility fire and life safety records were provided by the facility and reviewed with Staff 4 (Maintenance Director) on 12/09/25 at 3:15 pm. There was no documented evidence residents were instructed in fire and life safety procedures within 24 hours of admission and re-instructed at least annually. The need to ensure residents were instructed on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building within 24 hours of admission and to re-instruct residents on fire and life safety at least annually, with a written record of the content of the training sessions and the residents attending, per the OFC, was discussed with Staff 1 (ED) on 12/11/25 at 4:15 pm. She acknowledged the findings.

-The fire life and safety overview will be completed on day of move in for all residents and annually with whole building. -To correct this the instruction will be part of the move in process so that is done on move in day. Annually it will be scheduled for all residents with a month time period and repeatded anuually going forward. -The will be evaulated weekly during Maintennace and ED meeting. -The Maintenance director is responsible to complete and monitor.

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by:

All residents will be instructed on Fire life and safety procedures at move in. This will become part of the move in process. And then annually. The Fire life and safety procedures will be done as part of the move in process, and then scheduled in the maintance directors calandar to be done annually. This will be evaluated monthly to ensure everyone is up to date. The Marketing director will follow up with the Maintance Director on day of move in for initial instruction. The new move in and annual intstruction will be the Maintance Directors responsibility and monitored by the ED to ensure completion.

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by:

OAR 411-054-0093 (1-5) Emergency and Disaster Planning An emergency preparedness plan is a written procedure that identifies a facility's response to an emergency or disaster for the purpose of minimizing loss of life, mitigating trauma, and to the extent possible, maintaining services for residents, and preventing or reducing property loss. (1) The facility must prepare and maintain a written emergency preparedness plan in accordance with the OFC. (2) The emergency preparedness plan must: (a) Include analysis and response to potential emergency hazards including but not limited to: (A) Evacuation of a facility; (B) Fire, smoke, bomb threat, or explosion; (C) Prolonged power failure, water, or sewer loss; (D) Structural damage; (E) Hurricane, tornado, tsunami, volcanic eruption, flood, and earthquake; (F) Chemical spill or leak; and (G) Pandemic. (b) Address the medical needs of the residents including: (A) Access to medical records necessary to provide care and treatment; and (B) Access to pharmaceuticals, medical supplies, and equipment during and after an evacuation. (c) Include provisions and supplies sufficient to shelter in place for a minimum of three days without electricity, running water, or replacement staff. (3) The facility must notify the Department, the local AAA office, or designee, of the facility's status in the event of an emergency that requires evacuation and during any emergent situation when requested. (4) The facility must conduct a drill of the emergency preparedness plan at least twice a year in accordance with the OFC and other applicable state and local codes as required. One of the practice drills may consist of a walk-through of the duties or a discussion exercise with a hypothetical event, commonly known as a tabletop exercise. These simulated drills may not take the place of the required fire drills. (5) The facility must annually review or update the emergency preparedness plan as required by the OFC and the emergency preparedness plan must be available on-site for review upon request. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to conduct a drill of the emergency preparedness plan at least twice a year in accordance with the Oregon Fire Code (OFC) and other applicable state and local codes as required. Findings include, but are not limited to: The facility was a two- story licensed residential care facility that included two memory care units. During an acuity interview on 12/08/25 and other staff interviews throughout the survey, the resident census was identified at 67, with 16 residents who required the assistance of two staff for transfers (eight on the second floor, including four residents who required a mechanical lift for transfers, and eight on the first floor, including five residents who required a mechanical lift for transfers). During an interview at 3:10 pm on 12/09/25, Staff 4 (Maintenance Director) stated the facility had not practiced a full evacuation that included the residents who required two-person transfer assistance. Documentation of the facility’s emergency preparedness plan, including evidence that a drill of the plan was conducted at least twice a year, was requested on 12/11/25 at 2:14 pm. Staff 1 (ED) confirmed at the same time that the facility had not conducted a drill of the plan at least twice a year. The need to ensure the facility conducted a drill of the emergency preparedness plan at least twice a year in accordance with the OFC, and other applicable state and local codes as required, was discussed with Staff 1 on 12/11/25. She acknowledged the findings, and no further information was provided.

Scheduled simulated drills will take place in June and Nov of each year to ensure it becomes a standard exercise. -This will be a scheduled drill in all manager calandars for participation. -This will be evaluated twice a year for completion and admendments on the procudure to update for even more sucessful drills in the future. -This will be the maintenance directors responsibility to complete and will be monitored by the Maintence director and ED.

OAR 411-054-0093 (1-5) Emergency and Disaster Planning An emergency preparedness plan is a written procedure that identifies a facility's response to an emergency or disaster for the purpose of minimizing loss of life, mitigating trauma, and to the extent possible, maintaining services for residents, and preventing or reducing property loss. (1) The facility must prepare and maintain a written emergency preparedness plan in accordance with the OFC. (2) The emergency preparedness plan must: (a) Include analysis and response to potential emergency hazards including but not limited to: (A) Evacuation of a facility; (B) Fire, smoke, bomb threat, or explosion; (C) Prolonged power failure, water, or sewer loss; (D) Structural damage; (E) Hurricane, tornado, tsunami, volcanic eruption, flood, and earthquake; (F) Chemical spill or leak; and (G) Pandemic. (b) Address the medical needs of the residents including: (A) Access to medical records necessary to provide care and treatment; and (B) Access to pharmaceuticals, medical supplies, and equipment during and after an evacuation. (c) Include provisions and supplies sufficient to shelter in place for a minimum of three days without electricity, running water, or replacement staff. (3) The facility must notify the Department, the local AAA office, or designee, of the facility's status in the event of an emergency that requires evacuation and during any emergent situation when requested. (4) The facility must conduct a drill of the emergency preparedness plan at least twice a year in accordance with the OFC and other applicable state and local codes as required. One of the practice drills may consist of a walk-through of the duties or a discussion exercise with a hypothetical event, commonly known as a tabletop exercise. These simulated drills may not take the place of the required fire drills. (5) The facility must annually review or update the emergency preparedness plan as required by the OFC and the emergency preparedness plan must be available on-site for review upon request. This Rule is not met as evidenced by:

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: The

Copies of Plan of correction will be provided to all management members and each will be required to correct per plan by complaince date. Daily follow up to ensure corrections have been made, and manager discussion each morning on progress and completion in morning meeting. This will be evaluated each day till completed, and then on going evaluation it stays in compliance. Each department head and the ED will be responsible for conitued monitoring and compliance.

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by:

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to: On 12/08/25, the interior of the facility was toured, and the following observations were made: * Walls, doors, windowsills, and handrails throughout the building on the first and second floors had scrapes, gouges, and chips in the paint, exposing drywall and wood, which created non-cleanable surfaces; * Multiple chairs and a sofa in the MMC1, common area, had excessive wear, including large tears and rips in the material coverings creating non-cleanable surfaces; and * Coffee and water tables in MMC1, MMC2, and the RCF were observed to have water damage, with rust. The environment was toured and the need to ensure all interior materials and surfaces were kept clean and in good repair was discussed with Staff 1 (ED) and Staff 4 (Maintenance Director) on 12/11/25 at 10:02 am. They acknowledged the findings.

-Touch up to interior walls, doors, windowsills, hand rails, and walls will be patched repaired. -Plan is in place to replace furniture in MMC1 and MMC2. -Damaged or rusted drinking stations will be replaced. - updates are already in process of replacement. -This will be evaluated on daily walk throughs with Maintenance and Marketing departments. -Maintenance director will be responsible for completion and continued monitoring.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by:

The maintance director will paint areas with missing paint, front doors have already scheduled with vendor to repair- maintance will paint, courtyard doors will be painted, kitchen hallway will be patched and repainted,chair rails, hand rails will be patched and painted. Recliners are all being replaced- plan in place for all. Chairs that were seriously ripped were taken out. Bathroom walls will be cleaned and scuffs repaired. Resident doors and bathrooms needed painted will also be done. the system will be corrected by doing daily walk throughs and touching up areas as needed. The correction will be evaulated weekly to look for areas that are needing attention. The maintenance director will be responsible for corrections and monitoring.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by:

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint. This Rule is not met as evidenced by: Based on observation and record review, it was determined the facility failed to create an environment in which residents were treated with dignity and respect, were free from neglect, and received services in a manner that protected privacy for 3 of 6 sampled residents (#s 1, 2, 3, 5, and 6) and multiple unsampled residents. Findings include, but are not limited to: Refer to C200.

Please refer to C200 for plan of correction.

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint. This Rule is not met as evidenced by:

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C200, C231, C295, C363, C420, C422, C435, and C513.

Please refer to C200, C231, C295,C363, C420, C422, C435, and C513 for plan of correction.

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by:

Please refer to C231,C363,C420, C422, and C513 for plan of correction.

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by:

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff 18, 19 and 20 completed pre-service dementia training requirements prior to providing services to residents and demonstrated satisfactory performance in any duty they were assigned within 30-days of hire. Findings include but are not limited to: On 12/09/25, staff training records were reviewed and revealed the following: a. There was no documented evidence Staff 18 (MT), hired on 09/25/25, Staff 19 (CG), hired on 10/23/25, and Staff 20 (CG), hired on 10/23/25 had completed the following required dementia care trainings prior to providing care and working with residents independently: * Family support and the role the family may have in the care of the resident; * Behaviors that indicate change of condition; * Providing personal care to residents with dementia; * Orientation to service plans; and * Use of supportive devices with restraining qualities. b. There was no documented evidence Staff 19 and Staff 20 demonstrated satisfactory performance within 30-days of hire in the following areas: * Role of service plans; * Changes with normal aging; * Identification, documentation and reporting of change of condition; * Conditions that require assessment, treatment, observation and reporting; and * General food safety, serving and sanitation. c. Staff 18, had not successfully demonstrated satisfactory performance in the following areas: * Role of service plans; * Changes with normal aging; * Identification, documentation and reporting of change of condition; * Conditions that require assessment, treatment, observation and reporting; * General food safety, serving and sanitation; and * Medication administration. The need to ensure direct care staff completed pre-service dementia training requirements prior to providing services to residents independently and demonstrated satisfactory performance in any duty they were assigned within 30-days of hire was discussed with Staff 1 (ED) at 1:45 pm on 12/11/25. She acknowledged the findings.

-Staff in Memory Care will be assigned correct dementia specific trainings with a required completion date. -Staff who are missing the initial training classes will be assgined specific training with required completion date. -Caregiver and medication tech new hire checklists will be re-done to ensure satisfactory perfomance of required duties with a requried completion date. -This will be corrected and evaluation monthly. -The Business Office Manager and Wellness Coordinator will be responsible for completion and contiued montioring.

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. This Rule is not met as evidenced by:

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C252, C260, C303, C305, C310, C330, and C340.

Please refer to C252,C260, C303, C305,C310, C330, and C340 for plan of correction.

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by:

Please refer to tag C270 for plan of correction.

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by:

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure activity evaluations and individualized activity plans were completed for 2 of 3 sampled residents (#s 2 and 3) whose service plans were reviewed. Findings include, but are not limited to: Resident 2 and 3’s service plans offered some information about residents' interests, but the facility had not fully evaluated the residents' activity needs in one or more of the following areas: * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Activities which could be used as behavioral interventions, if necessary. There were no resident-specific activity plans developed from activity evaluations which detailed what, when, how, and how often staff should offer and assist the resident with more individualized activities. Observations made in MCC2 between 12/08/25 and 12/11/25 showed one group activity being led by facility staff on 12/09/25. The television was on in the unit, which played music or movies, and there were coloring pages, crayons, and colored pencils on a table. On 12/11/25 at 9:43 am, Staff 1 (ED) told a CG in the community about a painting activity starting at 10:00 am. She encouraged the CG to invite residents who were interested. No observations were made of the CG asking any residents if they wanted to join the activity, and no residents were taken to the activity at 10:00 am. The need to ensure activity evaluations were completed for all residents and individualized activity plans were developed and implemented was discussed with Staff 1 and Staff 3 (Wellness Director /LPN) on 12/11/25 at 12:35 pm. They acknowledged the findings.

-Activity profiles will be updated for current residents and done at move in for new residents. -Activity profiles will be givento wellness for appropriete updates to care plans, and a binder created for activites to keep and update as changes occur. -Activiy profiles will be addressed as changes in condition occur and at quartly evaluatons this will be initated by wellness management team to the activites department to assist in up to date accuracy. -This will be the responsibility of the activites department, Wellness Coordinator, and Wellness director to monitor and complete as changes or move ins occur.

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by:

Please refer to tag C270 for plan of correction.

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by: